Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning

We prospectively investigated the large-scale implementation of a respirato ry-therapist-driven protocol (TDP) that included 117 respiratory care pract itioners (RCPs) managing 1,067 patients with respiratory failure over 9,048 patient days of mechanical ventilation. During a 12-mo period, we reintrod uced a previously validated protocol that included a daily screen (DS) coup led with spontaneous breathing trials (SBTs) and physician prompt, as a TDP without daily input from a physician or "weaning team." With graded, stage d educational interventions at 2-mo intervals, RCPs had a 97% completion ra te and a 95% correct interpretation rate for the DS. The frequency with whi ch patients who passed the DS underwent SBTs increased throughout the imple mentation process (p < 0.001). As the year progressed, RCPs more often cons idered SBTs once patients had passed a DS (p < 0.001), and physicians order ed more SBTs (46 versus 65%, p = 0.004). Overall, SBTs were ordered more of ten on the medicine than on the surgical services (81 versus 63%, p = 0.001 ), likely reflecting medical intensivists' prior use of this protocol. impo rtant barriers to protocol compliance were identified through a questionnai re (89 respondents, 76%), and included: Physician unfamiliarity with the pr otocol, RCP inconsistency in seeking an order for an SET from the physician , specific reasons cited by the physician for not advancing the patient to a SET, and lack of stationary unit assignments by RCPs performing the proto col. We conclude that implementation of a validated weaning strategy is fea sible as a TDP without daily supervision from a weaning physician or team. RCPs can appropriately perform and interpret DS data more than 95% of the t ime, but significant barriers to SBTs exist. Through a staged implementatio n process, using periodic reinforcement of all participants in ventilator m anagement, improved compliance with this large-scare weaning protocol can b e achieved.